60% reduction in HIV risk with male circumcision, says WHO

Male circumcision should now be recognised as an important intervention to reduce the risk of heterosexually acquired HIV infection in men in high-prevalence countries, said WHO and UNAIDS in a position statement published in March.

In a keynote speech at the European Congress of Clinical Microbiology and Infectious Diseases in Munich (April 2), George Schmid (WHO, Geneva, Switzerland) said “combined data from three randomised controlled trials undertaken in Kenya, Uganda, and South Africa show that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.

This makes male circumcision the biggest news for tackling HIV prevention that we have had in years”.

Circumcision is one of the oldest surgical procedures in the world and about 30% of the global adult male population is circumcised. Research shows that countries or regions in Africa with low rates of male circumcision correlate with a higher incidence of HIV infection. According to Schmid, “Modelling data show that widespread implementation of male circumcision in southern sub-Saharan Africa, a high prevalence area, could prevent 2 million infections over a 10-year period. We therefore need to target adolescent men in these areas to see an immediate public-health benefit”. He added, “this is not an appropriate public-health intervention strategy for Europe”. Unpublished data from Uganda, said Schmid, shows that with half of all males circumcised, there would be a 25–30% reduction in new HIV cases in Uganda.

In a press conference, Schmid acknowledged a number of risks to scaling up male circumcision in these settings. “There may be adverse effects of the surgery itself, particularly in resource-poor settings where hospital hygiene may be poor. Additionally, men who get circumcised may develop a false sense of protection and engage in high-risk behaviours that could reverse the partial protection provided by circumcision”, he said.

The WHO/UNAIDS statement makes clear that circumcision needs to be part of a comprehensive prevention package, which includes the provision of HIV testing and counselling services, the promotion of safer sex practices, and the provision of male and female condoms. According to Kevin De Cock (WHO, Geneva, Switzerland), “it will be a number of years before we can expect to see an effect on the epidemic from such investment”.

Critics of the policy have raised concerns about uptake of male circumcision by the target population and whether already fragile health systems in African countries can cope. There is evidence, say WHO, to suggest that populations who do not traditionally circumcise their children will accept male circumcision. In 13 studies carried out in sub-Saharan Africa 65% of men reported being willing to be circumcised and 69% of women favoured circumcision for their male partners. “New research will explore the resources needed and the most effective ways to expand the necessary services in resource-poor countries”, said Schmid. As yet, evidence of any direct benefit of this intervention for women in high-prevalence areas is inconclusive.

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